Six CEOs and No Operating Room: The Impossible Job of Fixing the Indian Health Service
Rear Adm. Michael Weahkee is the current acting head of the IHS. (Gabe Johnson/The Wall Street Journal)
Three years ago, the U.S. Indian Health Service needed a savior for its hospital in Rosebud, S.D.
The federal health-care agency was forced to shut down the emergency department under pressure from federal regulators. Capt. Michael Weahkee seemed the man for the job, having run the IHS’s flagship hospital in Phoenix.
He launched quality-improvement efforts and got the hospital’s emergency department running again, before departing later that year to resume his Phoenix post. He signed off with a laudatory email to the Rosebud hospital staff: “For those of you who have weathered this storm, I salute you.”
His rise since then has been rapid. After running the agency on an acting basis for two years, now-Rear Admiral Weahkee — an officer in the U.S. Public Health Service Commissioned Corps — was nominated in October to be permanent director of IHS. His Senate confirmation hearing is scheduled for Wednesday.
Rosebud, however, continues to struggle. The operating rooms, which Adm. Weahkee shut in June 2016 in what was supposed to be a short-term disruption, remain closed. That is despite extensive efforts at renovation and hundreds of thousands of dollars paid for surgeons who couldn’t do their jobs because they had no place to operate. The hospital can’t deliver babies or do colonoscopies.
The turnaround stalled at Rosebud in part because of local mismanagement. Also to blame were the kind of enormous, agencywide challenges Adm. Weahkee will face if confirmed to the top job.
“Our hospital is like a MASH unit,” said Russell Eagle Bear, a Rosebud Sioux Tribe council member. “When people go to the emergency room, they basically fly them out.” Mr. Eagle Bear said he wasn’t speaking on behalf of the tribe.
Jerry Dale, an owner of Medical Air Rescue Co., said his company often flies at least three or four patients a week from Rosebud to regional hospitals. Each trip costs more than $8,000, he said.
For decades, policy makers in Washington have promised major improvements to the IHS, which is responsible for providing free health care to 2.6 million Native Americans under U.S. treaties. For many, the IHS is their sole source of health care.
Rosebud and some of the 23 other hospitals in the IHS system suffer from systemic problems, including leadership turnover, staffing shortages and facility breakdowns. There have been few signs of an overhaul under Adm. Weahkee, whose style is described as conciliatory by people who have worked with him.
While at Rosebud, “I achieved what I was sent there to do — to reopen the [emergency department] and move toward recertification [by regulators], which we have since successfully accomplished,” Adm. Weahkee said in a written statement.
IHS said Adm. Weahkee as acting director filled senior positions, created a quality-assurance arm and won funding for capital projects. The agency said Rosebud remains a priority and it has worked to improve the facility.
The president of the Rosebud Sioux Tribe said he endorsed Adm. Weahkee’s nomination, citing his qualifications, in a statement relayed by a tribal official. The tribe is also suing the IHS, alleging it provides inadequate care.
Adm. Weahkee’s job is a difficult one. He and his predecessors have struggled to gain attention in Washington. The agency has gone without a Senate-approved director since 2015. Many of its facilities are in remote areas where it is difficult to recruit skilled staff. Historically, local IHS leaders have operated with autonomy, making oversight from headquarters more difficult.
Overall, IHS spent about $4,078 per patient each in 2017, according to a report from the Government Accountability Office. That was about one third of what the Veterans Health Administration and Medicare spends per person.
Kerry Weems, a former official at HHS, said fixing IHS would require bringing per capita spending closer to the rate at Medicare, along with other changes. Neither Congress nor federal health officials have pushed for such major changes. Everyone shares culpability, said Mr. Weems.
President Trump nominated Adm. Weahkee to be the IHS’s permanent head after the first nominee, Oklahoma insurance broker Robert Weaver, withdrew early last year after a Wall Street Journal article showed that his résumé had misstated his experience. Mr. Weaver disputed the Journal’s reporting at the time and said that he was forced out.
After that, HHS officials contacted nearly a dozen executives who had overhauled large private-hospital systems, said a former Trump administration official. None were willing to raise their hands for the IHS job, the former official said.
“We conducted a search process, and have nominated the best candidate,” HHS said in a written statement. It said Mr. Weaver had withdrawn for personal reasons.
Several Native American groups have expressed support for Adm. Weahkee’s nomination, saying he has done a good job working with tribes. Adm. Weahkee, a member of the Zuni Tribe, has spent most of his career at the agency and was born at an IHS hospital in Shiprock, N.M.
“He’s very collaborative. He’s very thoughtful,” said Lynn Malerba, chief of the Mohegan Tribe, chairwoman of an IHS advisory committee. “It’s very difficult for any director to fulfill the treaty obligations of the Indian Health Service given what the structural and budget challenges are.”
Earlier this year, an investigation by the Journal and the PBS series FRONTLINE showed IHS officials had long suspected that a pediatrician, Stanley Patrick Weber, was a pedophile. Mr. Weber had been transferred from one facility to another after coming under investigation. He has been convicted of abusing six boys in two states, and is appealing.
In the wake of that report, Adm. Weahkee said problem employees no longer would be moved around. He overhauled abuse-reporting policies and required all workers to complete new training by September. It isn’t clear how much effect his efforts have had on the front lines.
In October, an agency hospital on the Standing Rock reservation in North Dakota failed a regulatory inspection after a cancer patient repeatedly accused a nurse of physically abusing her, including by punching her in the back. A video showed the nurse, Maria Wilkie, entered the patient’s room alone while a second nurse paced outside, according to the inspection report.
Ms. Wilkie’s supervisor, the hospital’s nursing director, told inspectors she “had no idea what to do” about an allegation of patient abuse by staff, had never received any training on the topic and that the hospital had no policy on it, the report said.
Ms. Wilkie denied abusing the patient and was suspended. She didn’t respond to requests for comment. She is now being considered for a nursing position at an IHS facility serving the Zuni reservation in New Mexico, people familiar with the matter said.
IHS said it is trying to do everything it can to protect patients and that its message is being heard in its facilities around the country. Training and policies at Standing Rock “may not have been specific enough,” it added.
The Rosebud hospital has changed CEOs at least six times since Adm. Weahkee departed in October 2016, including this Thanksgiving week. Many of them worked at Rosebud on only an interim basis. The agency has struggled to find people willing to accept the job full time.
Rosebud’s chief quality officer temporarily lost her nursing license in 2001 for drinking on the job at a prison where she then worked. Last month, just before an important quality-assurance inspection at Rosebud, the nurse, Carin Greenhagen, was charged with driving under the influence of alcohol or drugs in Arapahoe County, Colo., police records show. She missed the inspection, which Rosebud passed.
Ms. Greenhagen, who is scheduled to appear in court later this week, and the agency didn’t respond to inquiries about those events.
“We are making every effort to make staffing stability a priority” at Rosebud, the IHS said. The agency said funding nursing positions and recruiting in rural South Dakota remains difficult.
In May, Rosebud had a 40% vacancy rate for nurses. Last year, it had fewer than four patients on an average night at the 35-bed hospital. Nine other IHS hospitals had fewer than 10% of their beds filled on the average night in 2018, Medicare data shows. Nationwide, rural hospitals’ average occupancy rates are about 40%, according to the American Hospital Directory.
Scarce funds also mean that when IHS patients are referred to outside facilities for medical care, the agency can’t always pay for it, especially in cases not considered emergencies. In fiscal 2018, the agency estimated that its outside-referral program denied or deferred an estimated $677 million in care, or 163,058 services.
T.J. Heinert, a 25-year-old Rosebud Sioux Tribe member, went to the Rosebud emergency room on Aug. 11 after hurting his left ankle during a rodeo competition. An IHS doctor told him a major ligament was probably torn.
A physician assistant later asked the agency to authorize referrals to an outside hospital for a magnetic resonance imaging scan and to an orthopedic specialist, according to Mr. Heinert’s medical records.
Mr. Heinert said he was warned the requests probably wouldn’t be approved because of limited funds. “He said, ‘it’s not life-threatening,’ ” said Mr. Heinert, whose father is a South Dakota state senator.
Adm. Weahkee was sent in to fix things in May 2016. At that point, Rosebud had flunked a regulatory inspection and its emergency room had closed and the Rosebud Sioux Tribe had filed its suit arguing its health care was inadequate, a claim the government disputed.
At Rosebud, Adm. Weahkee’s five-man leadership team worked 12-hour days and lived in a government housing unit, said Adam Archuleta, one of the team members.
A few weeks after Adm. Weahkee arrived, a nurse anesthetist died. That forced the agency to close the operating rooms and stop delivering babies, saying it aimed to “resume these services as quickly as possible.”
Adm. Weahkee made a one-page list of goals dated June 22, 2016, including restoring emergency operations, regaining the trust of the Rosebud tribe and reopening the operating rooms. That July, he checked off a big one: The emergency department began taking patients again, using doctors from a staffing agency.
The operating room defeated him. Shannon Hopkins, who was deputy CEO at Rosebud in 2016, said she repeatedly brought the problems there to Adm. Weahkee’s attention. “He kept saying [the operating room] was a priority, but there was no action in place to follow that up,” she said.
The agency said its staff was working toward reopening the operating room.
At one point, agency officials realized they didn’t have proper climate controls in the operating room, which could increase infection risks, so workers attached monitoring sensors to one operating room wall with squares of surgical tape, according to a photo viewed by the Journal, staff notes and a July 2016 internal quality audit.
The next week, the team figured out that the tape could itself pose a sanitation risk. “[W]e need something more permanent,” an official wrote in an August 2016 work order. Later, officials realized they needed an estimated $1.2 million upgrade to the hospital’s dated HVAC system, a report by an outside monitor shows.
The agency disputed this account, but didn’t say which aspects were inaccurate. The IHS said it is replacing HVAC equipment throughout Rosebud.
That September, with the climate issues unresolved, Rosebud hired a general surgeon. Adm. Weahkee’s temporary stint in Rosebud ended the next month. The agency paid at least $420,000 over the next year for surgeons who had no place to operate.
“They got paid to sit around a lot of the day and not do anything,” said Ruth Thomas, a former Rosebud physician assistant.
The IHS said the surgeons saved money by screening patients before sending them for agency-paid treatment elsewhere.
In mid-2017, Adm. Weahkee moved from Arizona to IHS headquarters in the Washington area to become the agency’s acting director.
Back at Rosebud, the latest hold up in the operating suite came when it tried to install cabinets, a project that dragged on for more than six months.
“ ‘Oh my God,’ I would think. ‘You’re IHS. You’ve got the full weight of the federal government behind you. You can’t get that a little sooner?’ ” said Kevin Coffey, the CEO of Winner Regional Healthcare Center, a nearby private hospital who visited Rosebud during the construction.
By August 2017, more than a year after the closure of the operating rooms, new cabinets had been installed, according to people with knowledge of the matter. Then a surgical technician realized a new sink was too small to fit an instrument tray for cleaning, according to documents and people with knowledge of the matter.
Construction work had to resume. Staffers made plans to do the first colonoscopy on Oct. 18, 2017, according to internal planning documents.
It never happened. The operating suite still wasn’t ready.
The agency said it addressed the sink issue quickly and disputed it had immediate plans to reopen the operating suite at that time.
The U.S. hospital regulator returned in July 2018 to find the emergency room had again run afoul of federal rules. Among other errors, an intoxicated 12-year-old girl had attempted suicide while left unattended by hospital staff despite a previous effort to take her own life.
The agency made little effort in 2018 to reopen the operating suite, according to people with knowledge of the matter.
“The priority has been ensuring patient safety and establishing a sustainable foundation before” reopening the operating room, the IHS said.
By then, hundreds of thousands of dollars of equipment had been purchased for the suite, including a $230,000 endoscopy tower for which Adm. Weahkee had helped find funding in 2016, according to the goal list.
At the time, staff expected the operating room to open soon and wanted to prepare, the IHS said.
Current and former staff members say the endoscopy tower has never been used.